LUPRON DEPOT-PED Kit

Also known as Leuprolide Acetate. Coverage in Oklahoma (CMS PDP Region 23).

6 of 11 stand-alone Part D plans in Oklahoma cover this drug on tier 4–5.

6 of 6 plans apply a prior authorization, step therapy or quantity limit.

43 Medicare Advantage plans in OK do cover it

Medicare Advantage plans carry their own formularies, separate from stand-alone Part D. A patient on an MA-PD plan may have coverage even where no PDP lists the drug. OK: 43 plans.

Every plan that covers it

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$65.40/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$26010.4953	—	Prior authorization
HealthSpring Assurance Rx (PDP)$126.50/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$26014.0084	—	Prior authorization
Blue Cross MedicareRx Basic (PDP)$0.00/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$26902.6334	$4,842.470.18 units	Prior authorization Quantity limit 1 per 168 days
AARP Medicare Rx Saver from UHC (PDP)$82.40/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$28397.8916	$5,111.620.18 units	Prior authorization Quantity limit 1 per 168 days
AARP Medicare Rx Preferred from UHC (PDP)$121.00/mo premium · $130.00 deductible	5Specialty Tier	31%	—	$28397.8916	$5,111.620.18 units	Prior authorization Quantity limit 1 per 168 days
Blue Cross MedicareRx Value (PDP)$167.30/mo premium · $615.00 deductible	5Specialty Tier	25%	—	$26655.8636	$4,798.060.18 units	Prior authorization Quantity limit 1 per 168 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity.

See coverage in all 39 regions →